Medicare prescription drug exception & appeal form — to request an authorization, formulary exception (for a drug that is not on our formulary), or a tiering exception (to pay less for a covered drug because you can’t take a lower-cost drug), or an appeal if we deny coverage for your drug or deny your exception request. For exception requests, your doctor must call or write us to explain why it is medically necessary.

Hospice pharmacy authorization request form — if there is a question as to whether a drug should be covered under your prescription drug benefit (Part D) or hospice benefit, you or your doctor can submit this form to our Pharmacy Team for a coverage determination.

Claims

Medical reimbursement form — if you paid out-of-pocket for a covered medical service, including vision, dental, or hearing services

Premiums

Automatic payment form — if you would like to have your premium automatically withdrawn from your monthly Social Security payment, withdrawn from your bank account each month or charged to your credit card